Submitted by: Raquel Reyes, MD, MPA, PGY3, Internal Medicine and Pediatrics, Massachusetts General Hospital.
This experience has afforded me the opportunity to see more than MDR-TB, and more than a single health institution. Over the past week and a half, we have traveled to Gondar to visit Gondar University Hospital, where we met with the new CEO and got to see the MDR-TB ward there. We also met with the head of the Department of Pediatrics at Black Lion Hospital, Dr. Demte, and attended morning report and morning rounds. We visited the Missionaries of Charity (from where several of the MDR-TB patients at St. Peter�s were initially referred). We met with the local head of the Clinton Foundation and had the opportunity to discuss their new Maternal, Newborn, and Child Health initiatives. It has been a full week.
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More than MDR-TB at St. Peter�s.
Approximately 1/3 of the patients in the GHC/St. Peter�s MDR-TB cohort are co-infected with HIV. All MDR-TB patients have initial laboratory evaluation including CBC, LFTs, bilirubin, creatinine, potassium, and HIV screening. Some patients are known to be HIV+ at the time of enrollment into a Category IV treatment program.
Such was the case for Zewdu, a 43yo man I met my first day on rounds. He was complaining of some vague abdominal pain as well as nausea, loss of appetite, and bloody diarrhea. His stool had already been sent and was negative for O&P. His exam was notable for diffuse abdominal tenderness to palpation and moderate distention. I looked through his chart and saw that his most recent CD4+ count was 36, down from 54 a few months earlier. I wondered whether he might have CMV. I also wondered about c. diff, as he had been on levofloxacin for his TB for some time. Neither of these were testable. I looked over his ARV regimen which included tenofavir, lamivudine, and efavirenz as well as clotrimoxazole prophylaxis. We sent a viral load. The next day his diarrhea was essentially resolved and he reported ongoing nausea and anorexia but improved abdominal pain. His abdominal exam was still notable for diffuse mild tenderness to palpation most prominent in the RUQ as well as mild distention. He seemed stable overall but he was definitely not thriving. We sent LFTs, electrolytes, and glucose. I wondered about CMV and c. diff (although neither can be easily tested for here). The next day he reported he had been able to take some liquids and was feeling generally better. He remained stable over the next several days.
When we returned to St. Peter�s from our visit to Gondar, however, Zewdu had taken a turn for the worse. We were rounding on some of the patients in the upper ward when a nurse came to us and requested our assistance with a critical patient. As I walked with Dr. Bekele toward the room, I asked for the one-liner. He told me that a patient was in a coma. �A new patient?� I asked. �No, no, you know him.� �One of the patients I know is in a coma?!? Who is it?� �It is Zewdu.� We arrived to the bedside, and there was Zewdu, lying flat, eyes open, with slow, stridorous breaths, not moving. He did not even resemble the man I had met 12 days before. He moaned and grimaced to sternal rub but did not localize. He had apparently been relatively normal about an hour earlier. 40% glucose had already been administered. We asked that an additional glucose bolus be given. His other vital signs were normal. One of his roommates (he was in a 6-bed room) told us that he had been seizing over the weekend. Shortly after he told us this, Zewdu seized; it began with right-sided convulsions and secondarily generalized. We raised the head of his bed and positioned his head. We gave him supplemental oxygen. We administered 10mg IM diazepam in case he was in status. We ordered him for IV dexamethasone, a loading dose of phenobarbital, meningitic dose ceftriaxone, and empiric treatment for toxoplasmosis. LP is not possible at present (due to lack of adequate sterilization of the LP equipment). We asked for CBC, Blood culture, chemistry 20. Zewdu never woke up. He never received the phenobarbital or the pyrimethamine. He expired at around 6pm. His labs still have not come back.
Once again, I want to recall and document that most of the MDR-TB cohort patients, including those with HIV/AIDS, are surviving. One patient proudly boasted to me about his last few CD4 counts, which were initially decreasing on the TB medications (common) and are now on the rise again. I wanted to write about Zewdu because I wanted to highlight the challenges of practicing medicine in a resource-limited setting with such serious illnesses. Physicians here practice with limited diagnostic as well as limited treatment options. And a greater proportion of their patients are so much sicker than the patients we treat back home. I also wanted Zewdu�s story to be told. As I wanted Girmay�s story told. And Abde�s. But GHC/St. Peter�s stories also are the ones that turn out well. In fact, most of them are the ones that turn out well. And these are also fraught with difficulty. People living in tiny single-room homes with almost no ventilation. People without refrigerators or electricity to safely store their medications. People suffering from food insecurity. People who have lost brothers, sisters, parents, children. People who have lost their jobs, their only source of income, due to their illness. And these people are being cured and getting well and their lives are improving.
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| Mural at the Missionaries of Charity |
More than MDR-TB at Missionaries of Charity
On Tuesday we went to the Missionaries of Charity, known for the work of Mother Theresa. At the mission in Addis Ababa, which is near to St. Peter�s Hospital, approximately 900 people live there. Most of them have some form of medical or mental illness and have nowhere else to go. The Sisters of Charity care for men, women, and children with not only tuberculosis, but also different types of cancers and growths, infections (including HIV), disabilities including limb amputations, skeletal deformities, and blindness, severe mental illness, severe malnutrition, seizure disorders, congenital anomalies, and those who have simply been abandoned by all family and cannot care for themselves. There are many orphans and unwanted elderly. It is crowded, with as little as 5 inches between beds, but it is also almost spotless. It is neat and orderly. All of the beds in a given room have the same sheets. All of the equipment is uniform and in good condition.
GHC/St. Peter�s has focused on providing care for patients from the Missionaries of Charity from the very beginning of the program to make sure that the poorest in Ethiopia also had access to care. Some of the first patients to receive Category IV treatment were from the Missionaries. This week we met Helen, a young woman with an 18 month-old baby boy. She has confirmed MDR-TB and is wasting away. After it was discovered that she has MDR-TB, the sisters were able to move the several other beds in her room into another room to decrease the contact between Helen and the other women in the TB ward. Still, to get to her room you have to walk through a few other rooms with 6 or so patients each; definitely not ideal. She was thin, her heart was tachycardic, her respiratory rate in the 30s. Her lungs had crackles on the left and diminished air entry. Her artificial leg (she had to have a left AKA after an infection when she was younger) is causing her significant pain because it was fitted for her when she was about 20kg heavier.
With the arrival of more TB medications, Helen was able to be admitted to St. Peter�s for treatment yesterday. Next week I will go back to the Missionaries to take photos with her boy and bring them to her.
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| Helen's boy, Josef |
More than MDR-TB at Black Lion Hospital
This week we went to the Black Lion Hospital, which is the main teaching and referral hospital for the country. It is large, and right in the middle of Addis.
We met with Dr. Demte, the head of the Pediatrics Department, and attended morning report and morning rounds. There is a NICU and a PICU (although no ability to ventilate patients). The children here are sick, sick, sick. We met one 2 year-old boy, Abu, with suspected MDR-TB (he has continued to get worse despite adequate Category I therapy, with loculated empyema and chest tube in place) and will try to facilitate testing of his sputum so that he can get treatment if he needs it. We also met several children with bacterial meningitis, children admitted with heart failure, renal failure, rhabdomyosarcoma, osteosarcoma, retinoblastoma, severe pneumonia, several children with infected meningomyeloceles, one child with tetanus, three with septic arthritis, several with complicated malaria, a few with severe acute malnutrition.
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| CXR Bad TB in 2yo boy |
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| CT Bad TB in 2yo boy |
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Over the past week and a half we have also participated in home visits for the MDR-TB patients. We�ve met with officers from the Ministry of Health and the Ministry of Science and Technology. We�ve seen many different aspects of health care and clinical practice at multiple institutions. It has been an extremely worthwhile learning experience.
I can�t believe my time here is already more than halfway finished. In addition to daily rounds at St. Peter�s, my goals for the remaining time are as follows: 1) go back to the Missionaries of Charity to take photos with Joseph, Helen�s son and to let the Sisters know that she is doing well; 2) return to Black Lion to attend some morning reports, grand rounds, and morning rounds, checking on Abu; 3) draft some Quality Improvement suggestions for GHC/St. Peter�s; 4) develop flowsheets/clinical guidelines for the nurses and health workers at St. Peter�s; 5) participate in additional home visits.
Less than two weeks left!
Raquel.
